07-11-2007 Council Agenda - Laserfiche WebLink

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Minnesota Lawful Gambling L0230 Application to Conduct Off -Site Gambling No Fee 5/04 Licensed Organization Inform�atti9n lease print 111 formation) �0�� Organization name a% Y40iyl %�/ 7 , 1 ; -7 License number License expiration date o 3 / 3/ l,2-0' ?� Daytime phone number X0.5 /-7be`7`USJ1 / Name of chief executive officer �n `l,17 r✓ 6/v (Do not list the gambling manager) Gambling Activity 1. Name of establishment or function where gambling activity will be conducted (7/9-71//61-19,19-A) .�� A S M,� / AL,CL 2. Street address and city 5 / �Oo /(� -- £z/ ./ AO &)7�g 49 tA9 4 y a'A (Do not use a post office box. If no street address, write in road designations. Example: 3 miles east of Hwy. 63 on County Road 42) 3. Does your organization own the gambling premises? _Yes If yes, a lease is not required. 1, No If no, a lease agreement must be attached. You may use lease form LG224, available from the Board. NOTE: A lease is not required for raffles. 4. Check the gambling activity your organization will be conducting. ✓oull -tabs raffles paddlewheels _bingo�nt''_tipboards 9 5. Date of single day event 9'ru �' 3 —t) ZO,(4 separate days allowed per calendar year) 6. Dates of up to 12 consecutive days in connection with a county fair, the state fair, a church festival, or a civic celebration. Begin date ,4iit3 End date, n t16 52 Z4V7 (1 event allowed per calendar year) Acknowledgment and Oath I have read this application, and all information is true, accurate, and complete. Chief executive sign_ - /L�/�.�: /` /.� .� i� Date 40Z/ 70 /V7 ,ii/ The person signing this applicatio ust _be the CEO of your organization and have his or her name on file with the Gambling Control Board. If the CEO has changed during the term of your license and has not fled a LG200B Organization Officers Affidavit with the Gambling Control Board, he or she must do so at this time. Application and attachments: At least 30 days prior to the activity date, submit: 1) this application, 2) the resolution of approval from the local unit of government (city or county), and 3) a copy of the lease agreement (no lease required if your organization owns the premises or for raffle activity) There is no application fee. Mail to: Gambling Control Board Suite 300 South 1711 West County Road B Roseville, MN 55113 Questions? Contact your licensing specialist at 651- 639 -4000. If you use a TTY, you can call the Board by using the Minnesota Relay Service and ask to place a call to 651- 639 -4000. This publication will be made available in alternative format (i.e. large print, Braille) upon request. The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine yourqualificationstobe involvedin lawfulgambling activities in Minnesota, andto assist the Board in conducting a background investigation of you. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issueyou a permit. Ifyou supply the information requested, the Board wit be able to process yourapplication. Thisform may require the disclosure of your Social Security number. If so. your Social Security number will be used to determine your compliance with the taxlaws of Minnesota. Authorizationforrequiting your Social Security number isfound at42 U.S.C. 405 (c)(i). Your name and address will be public information when received by the Board. All the other information that you provide will be private data aboutyou until the Board issues your permit. Mien the Board issues your permit, ail of the information that you have provided to the Board in the processof applying far your permitwill become public except for your Social Security number, which remains private. If the Board does not issue you a permit, all the information you have provided in the process of applying for a permit remains privates with the exception of your name 2- and address which will remain public. Private data about you are available only to the following: Board members, staff of the Board whose work assignmentrequires that they have accesstothe information; the Minnesota DepartmentofPublic Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this Noticewasgiven; and anyonewith yourconsent. 7/7